Introduction to the case

Pt. presented to my office w/ multiple congenitally missing teeth and existing upper/lower acrylic partials. She finally made up her mind to move into implants to improve her quality of life. For #7, a Nobel Replace select 3.5 X 11.5 was placed and immediately temped w/ a screw retained provisional made over a plastic engaging cylinder w/ access hole through the cingulum. Tooth was taken out of occlusion and all excursions. Pontic was easily cut off her existing partial. I placed the top of the implant 3mm apical to where I wanted the margin of the facial tissue to settle, which buried the implant .5-1mm subcrestal. A final radiograph was taken w/ the screw retained temp in place and I noticed that the cylinder was not completely seated, probably because of the subcrestal placement. Being this is a provisional restoration, I didn’t think much of it, but was curious to see everyone’s thoughts.

When I made the provisional, I screwed down the engaging cylinder, but did not take a confirmation radiograph (mistake?). I then loosened the screw so I could pull the cylinder out with the luxatemp synch impression (mistake?). Either one of these reasons could be why the cylinder was not seating all the way on the final X-ray. Would like to hear everyone’s thoughts and comments about how they make this type of screw down provisional and if they would be concerned that it is not seated all the way. Thanks

Introduction to the case

Tooth #3 with 2 DB roots! This was something I have never seen before, 2 completely separate DB roots! Patient came in with extreme pain to hot and cold. A diagnosis of SIP with Normal Apical Tissue was made. Pt is aware that there was deep decay and will need CCL. There were Two MB canals, Two DB Roots and a palatal root as well. 5 Canals!

Introduction to the case

In the time I’ve been around guided surgery, I’ve gotten to hear all the excuses why people don’t get on board. Some of them are very valid and I even used them myself at one time. One objection is it’s not accurate. It is accurate – far more accurate than what can be accomplished free hand.

But the much more valid arguments were that it was too cost prohibitive (which it was), that it was a lot of work (which it was), and that there were just too many moving parts making the process complex (which there were). Well, I’m pretty excited to share this because these concerns are now going to just evaporate.

The cost and complexity were due to the fact that you needed a CBCT, an optical scanner, an expensive printer, and expensive software to do it yourself, or you had to farm out different parts of the process like scanning or printing to 3rd parties. Now, you’ll be able to do the whole thing in house. The only barrier to entry is the CBCT which is necessary, but you can certainly refer it out to someone – you don’t have to own it.

But now, it’s gotten even better. Now, we can simply scan just an impression without even needing to pour it up. Blue Sky Plan allows us to turn that cone beam scan of the impression into an STL file which can then be “digitally poured” to create the actual STL. This digital pour is done in another free program currently but we’ll eventually have the entire functionality within Blue Sky Plan simplifying it even further. This is a workflow originally figured out by Dr. Rick Ferguson.

This is a notable improvement over scanning the stone models because you almost always have a little bubble in the stone that translates into an error in the guide built on it which will have to be adjusted out for proper fit in the mouth.

With an impression, you might possibly have a bubble, but that’s a positive error that would not affect the fit of the guide – when you “digitally pour” it, it would equate to a bleb on the model.

Also, I actually prefer getting the STL from a scan of PVS putty impression rather than getting the STL from an optical scanner or a CBCT scan of a stone model because the latter two can sometimes be TOO accurate. They pick up every little nook and cranny and then the guide gets built on that and it goes into every nook and cranny too. Then you have to adjust the guide a bit to prevent binding. By using PVS putty, the impression is slightly less detailed, it’s almost like what you would get if you lightly waxed out the embrasures.

So now, you get your STL and your cone beam data from just your CBCT machine. The second major development is that we’ve been testing the Cel Robox printer and the results have been great. This printer is $1500 and if all you’re doing is a guide or 2 a day, it’s sufficient for our purposes and uses food safe materials.

So now, it’s totally realistic to scan the patient and their impression in the morning, plan the case, and have the guide printed by lunch time.

Introduction to the case

25 years ago I started restoring these fractured cusps this way and have only lost a couple of the 20-30 plus teeth I have restored this way. Conventional treatment has been extraction in many cases. Some have had previous RCT.

Procedure:
I percolate Javex or bleach (same stuff I use for RC) into the fracture to clean any organic crap out and help just clean the fracture line. Then I wash profusely for 20 seconds to get rid of the bleach. Then dry and etch moving the piece open and close to suck and pump the etch down the crack. Then wash for 3 seconds and since I am using a 4th generation bonding system I place 5-6 coats of primer on the tooth and use a little more than usual to get the primer down the crack. This will take me close to 60 seconds to place these coats of primer and let it evaporate for several seconds between coats. I will sometimes write up my chart while I wait for the primer to evaporate but I know I will get a hybrid layer and good bonding results this way. Then I dry for 5 seconds and liberally apply my bonding resin and push the piece together and cure with my Valo for 20 seconds. My resin is dual cure so it cures well. The tooth is sealed and should function just fine as have the other couple of dozen I have restored this way. Some were restored this way 25 year ago and still working!

Introduction to the case

This is one of my earliest cases using the Greater Curve matrix. The Greater Curve matrix was introduced in 2006. Today, I would have built up the mesial and then squished the partial into a sea of soft composite.

Introduction to the case

This patient has almost perfect teeth, but then developed external resorption of their upper right central incisor. They saw an endodontist who told the patient that it wasn’t restorable, and then the patient found their way to me. The patient has kindly allowed me to show their case.

Introduction to the case

This patient has almost perfect teeth, but then developed external resorption of their upper right central incisor. They saw an endodontist who told the patient that it wasn’t restorable, and then the patient found their way to me. The patient has kindly allowed me to show their case.